The undersigned hereby authorizes Dr. Khanna to take X-ray, study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Khanna to make a thorough diagnosis of the patient’s dental needs. I also authorize Dr. Khanna to perform any and all forms of treatment, medication, and/or therapy that may be indicated. I also understand the use of an anesthetic agent embodies a certain risk.

I understand that payment is due in full at the time of service unless alternative financial arrangements have been made with Khanna Dentistry in advance in writing. I understand that late fee will be added to any overdue balances.

I understand that where appropriate, credit reports may be obtained.

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

Medical History( * mandatory to fill )

Are you under a physician care now?

Yes

No

If yes, please explain

Have you ever been hospitalized or had a major operation?

Yes

No

If yes,

Have you ever had a serious head or neck injury?

Yes

No

If yes,

Are you taking any medications, pills or drugs?

Yes

No

If yes,

Do you take, or have you taken,phen-fen or Redux

Yes

No

If yes,

Have you ever taken Fosamax, Boniva,actonel or any other medications containing bisphosphonates?

Yes

No

If yes,

Are you on a special diet?

Yes

No

If yes,

Do you use tobacco?

yes

no

Women, are you?

Pregnant/trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin

Pencillin

Codeine

Acrylic

metal

Latex

sulfa drugs

Local anesthetics

Other

If Other,

Do you use controlled substances?

Yes

No

If yes,

Other

If Others,

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Yes

No

Alzheimer Disease

Yes

No

Anaphylaxis

Yes

No

Anemia

Yes

No

Angina

Yes

No

Arthritis/Gout

Yes

No

Artificial Heart Valves

Yes

No

Artificial Joints

Yes

No

Asthma

Yes

No

Blood Disease

Yes

No

Blood Transfusion

Yes

No

Breathing Problems

Yes

No

Bruise Easily

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Cold sores / Fever blisters

Yes

No

Congenital heart disorder

Yes

No

Convulsion

Yes

No

Cortisone medicine

Yes

No

Diabetes

Yes

No

Difficulty Breathing

Yes

No

Drug Addiction

Yes

No

Easily Winded

Yes

No

Emphysema

Yes

No

Epilepsy or Seizures

Yes

No

Excessive Bleeding

Yes

No

Excessive Thirst

Yes

No

Fainting spells / Dizziness

Yes

No

Frequent Cough

Yes

No

Frequent Diarrhea

Yes

No

Frequent Headaches

Yes

No

Genital Herpes

Yes

No

Glaucoma

Yes

No

Hay Fever

Yes

No

Heart Attack / Failure

Yes

No

Heart Murmer

Yes

No

Heart Pacemaker

Yes

No

Heart Trouble / Disease

Yes

No

Hemophilia

Yes

No

Hepatitis A

Yes

No

Hepatitis B or C

Yes

No

Herpes

Yes

No

High Blood Pressure

Yes

No

High Cholesterol

Yes

No

Hives or Rash

Yes

No

Hypoglycemia

Yes

No

Irregular Heartbeat

Yes

No

Kidney Problem

Yes

No

Leukemia

Yes

No

Liver Disease

Yes

No

Low Blood Pressure

Yes

No

Lung diseases

Yes

No

Mitral Value prolapse

Yes

No

Osteoporosis

Yes

No

Pain in Jaw Joints

Yes

No

Parathyroid Disease

Yes

No

Psychiatric Care

Yes

No

Radiation Treatments

Yes

No

Recent Weight Loss

Yes

No

Renal Dialysis

Yes

No

Rheumatic Fever

Yes

No

Rheumatism

Yes

No

Scarlet Fever

Yes

No

Shingles

Yes

No

Sickle Cell Disease

Yes

No

Sinus Trouble

Yes

No

Spina Bifida

Yes

No

Stomach/Intestinal Disease

Yes

No

Stroke

Yes

No

Swelling of Limbs

Yes

No

Thyroid Disease

Yes

No

Tonsillitis

Yes

No

Tuberculosis

Yes

No

Tumors or Growths

Yes

No

Ulcers

Yes

No

Venereal Disease

Yes

No

Yellow Jaundice

Yes

No

Have you ever had any serious illness not listed

Yes

No

If yes,

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my(or parents) health.nIt is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

TMJ History( * mandatory to fill )

Have you ever had or been diagnosed with a problem with either Jaw Joint?*

Yes

No

If yes,*

Does your jaw click, pop or make noise when you open and close?*

Yes

No

If yes,*

Has your jaw ever locked open or closed?*

Yes

No

If yes,*

Do you ever have pain or tenderness in your jaw joint when you open, close or chew?*

Yes

No

If yes,*

Do you have frequent headaches?*

Yes

No

If so, how often?*

Do you clench or grind your teeth, or ever been told that you do?*

Yes

No

If yes,*

Have you ever had trauma to your chin or jaw?*

Yes

No

If yes,*

PERSONAL DENTAL NEEDS SURVEY( * mandatory to fill )

Please rate on a scale of 1-5 the importance of each of the following regarding your dental care. (1 = most important)

Preventative Dental Health Care

1

2

3

4

5

Freedom from pain

1

2

3

4

5

Excellence and quality of Service

1

2

3

4

5

Cost and Affordability

1

2

3

4

5

Other

If Other,

Please rate on a scale of 1-3 what a dentist must do to gain your confidence.

Show me what he/she is doing or needs to do so I can clearly understand what is happening

1

2

3

Listen to my concerns and explain thoroughly the procedures to be performed.

1

2

3

Make sure I feel comfortable and informed at alltimes

1

2

3

Please circle the level of fear you have about your dental visits (10 being the greatest fear)

1

2

3

4

5

6

7

8

9

10

I would like to know about these options available to me for maximizing my comfort and my experience during my visit. Check all that apply

Music or Movie with headphones

Nitrous Oxide

Sedative Medications (oral and/or I.V.)

Patient Education Material

Neck Wraps

Blanket

Other

Please list your preferred music type

Please specify if others,

Are you concerned about the following

Existing Discomfort

Yes

No

Whitening your teeth

Yes

No

Replacing old silver fillings

Yes

No

Appearance of my smile

Yes

No

Recurring or untreated gum disease

Yes

No

Prevention of decay

Yes

No

Mouth odor

Yes

No

Other

Yes

No

If others

Please check one answer for each of the following:

When discussing my treatment plan, I prefer

The big picture

Detail by detail

When evaluating my smile, it is more important

What I see

What others see

Financial Terms( * mandatory to fill )

Thank you for choosing Khanna Dentistry as your dental healthcare provider. We are dedicated to providing the highest quality of care possible. We are also committed to providing our patients clear and straightforward information regarding their financial responsibilities. The following is a statement of our Financial Terms that we require you to read and sign before treatment.

Patients without Insurance Coverage: Full payment is due at the time of service unless alternative financial arrangements have been made with Khanna Dentistry in advance and in writing. For your convenience, we accept cash, personal checks, and all major credit cards.

Insurance Patients: Dr. Khanna does not participate in preferred provider programs. Payment will be expected pay in full at the time of service and the insurance company will reimburse you directly. As a courtesy to you, we will submit all insurance claims and supporting documents to your insurance company. Please remember, it is still your responsibility to alert us of any changes in your insurance coverage. Please bring your insurance card and all pertinent information that will allow us to determine the benefits available to you or if there have been any changes in your benefits.

Returned Checks: Patients whose checks are returned from the bank due to non-sufficient funds will incur an additional fee of $35.00

Past Due Accounts: Past due accounts are referred to a collection agency. A collection fee ranging from $25 to up to 35% of all the balance due may be added to your unpaid balance to recover costs of collections. You will also be responsible for any and all attorneys’ fees, court costs and any other fees associated with the collection of your debt.

Extended Payment Plans: All extended payment plans are done through Care Credit, which is a third-party financing company. They offer a wide variety of payment options including some interest-free payment plans. If you have any questions about applying for a Care Credit account, please speak with our Treatment Coordinator.

Broken or Missed Appointments: An appointment is considered broken if it is not kept or if it is changed with less than 48 hours notice to us. Broken and missed appointments prevent other patients from receiving the dental care they require. Our practice takes all of our patients and their appointments seriously, so please be considerate and inform us at least 48 hours in advance if you need to change your appointment.

Fee for Missed Appointment if 48-Hour Notice is Not Given: To reschedule or cancel an appointment, you must notify us at least 48 hours in advance to avoid a missed appointment fee of $100.00.

If you have any questions regarding your account, please contact our office at 630-845-1088. Thank you for understanding and accepting our financial policy.

I have read and agree to the terms of this Financial Term:

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

PHOTO RELEASE FORM( * mandatory to fill )

Neeraj Khanna DDS

Khanna Dentistry, P.C.

425 Hamilton St

Geneva, IL 60134

Permission to Use Photographs

Subject: Dental Photography

I grant Dr. Neeraj Khanna DDS, its representatives, and team members the right to take photographs of me, my mouth and teeth in connection with the above-identified subject. I authorize Dr. Neeraj Khanna, its assigns, and transferees to copyright, use, and publish the same in print and/or electronically.

I agree that Dr. Neeraj Khanna DDS may use such photographs of me with my name for any lawful purpose; including, for example, such purpose as educational lecturing, illustration, advertising, and Web content.

I have read and understood the above:

I Refuse to release the information

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

APPOINTMENT AGREEMENT( * mandatory to fill )

Our time is valuable and so is yours. Our commitment to you is:

• We always try to make appointments that are convenient for you.

• We will not ask you to make a schedule change unless it is an extreme emergency or of a potential benefit to you.

• We will always be respectful of your personal time and will make every effort to start your dental appointments on time and complete your treatment as efficiently as possible.

Please understand that we reserve chair time just for you when you make an appointment with us. In an effort to continually provide quality service, we ask that you keep your reserved time as it is scheduled. Please give our office 48 hours(or more, if possible with the exception of extreme personal emergency) notice if you need to change your appointment or a fee will be assessed to your account based on the amount of time scheduled, at the rate of $100 per hour.

Please keep us informed of any changes to your health information and medications as well as your address, phone, email or insurance information so that we may serve you in the best possible manor.

I have read and understand the above financial policies. I authorize release of any information pertaining to treatment for the purpose of comprehensive filing of insurance claims. I authorize payment of primary insurance benefits directly to the dentist otherwise payable to me. I acknowledge full responsibility for the payment of services at the time of service unless other arrangements are made with this office.

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION( * mandatory to fill )

SECTION A: PATIENT GIVING CONSENT

Name

Address

City

State

Zipcode

Phone

Email

SECTION B: TO THE PATIENT-PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decided whether to sign this Consent. Our Notice provides a description of our treatment, payment, activities and healthcare operations of the uses and disclosures we may make of your protected health information and other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice at any time by contacting:

Contact Person: Office Coordinator/Practice Manager

Phone: 630-845-1088 Fax: 630-845-1088

Address: 425 Hamilton Street, Geneva, IL 60134

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this Consent.

I,

Enter Patient Name

, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent Form I am giving my consent to your use and disclosure of my protected health information to carry out treatment; payment activities and health care operations.

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

DENTAL BENEFIT AGREEMENT( * mandatory to fill )

Your dental benefits help offset the investment of getting quality dental care performed on you and your family and it is our pleasure to assist you in maximizing your insurance benefits by completing your claim forms. Please be aware that your coverage depends solely on what your employer wishes to purchase. Some plans cover as little as 30% or as much as 100% of dental services, with most falling in the 40%-80% range. Some plans base the amount of benefit on the schedule of fees arbitrarily developed by insurance companies. For this reason, you may receive a lower percentage than the reimbursement level indicated in your dental plan.

For example, if your plan states that it will pay 80% of the cost of a specific treatment, it means 80% of the fee arbitrarily determined by the insurance company and not the actual fee charged by a dental office, ours or otherwise. Please understand that any assistance concerning what or how much coverage you have, whether by phone or mail, is for reference only and should not be your only basis for proceeding with or denying treatment.

We do not base our treatment recommendations on what the insurance company will cover but rather what the best treatment is for you. We will assist you in any way that we can (including electronic claims submission and submitting pre-determinations). In addition, because of the inconsistencies in secondary insurance benefits, we do not consider the secondary benefits when figuring your potential portion of the charges.